The Pharmaceutical Journal
Vol 278 No 7446 p386
7 April 2007

This article
Reprint   Photocopy

PDF 30K, Acrobat Reader

It's not rocket science more
Respect patients and see health improve more

It's not rocket science

So much was expected of the National Patient Safety Agency when it was launched in 2001 that it was bound to struggle to make its mark. Indeed, a relatively small arm of the Department of Health had little chance of changing the culture of a monolith like the NHS, or of making staff change their behaviour overnight so that patients would be less at risk when things went awry. The cornerstone of the approach was to ask members of staff to report anything that went wrong (or nearly went wrong), to learn from their mistakes and the mistakes of others, and to accept that blame was a thing of the past — when it patently was not. With the benefit of six years’ hindsight it is easy to see why the NPSA might not have had the impact that its creators hoped.

Last week, the NPSA launched a series of alerts with support materials that are practical, simple and, arguably, easy to put in place. They do not require changes in behaviour on any grand scale; rather they advocate a re-engineering of processes so that many mistakes can no longer occur. A good example is making it physically impossible for liquid oral medicines to be delivered intravenously by ensuring that only oral and enteral syringes are ever used. Another is never storing bags of epidurals together with bags of intravenous infusions so that there is less possibility of a mix-up (see News feature p392). None of this is rocket science.

Perhaps harder to crack is ensuring that patients prescribed anticoagulants in hospital really understand that they need to have blood levels checked regularly once they are discharged.

Nevertheless, the systems recommended by the NPSA should not be hard to implement. Maybe giving ownership to pharmacists, as proposed, will be one way of ensuring that practice changes. Let us hope that in, say, as little as two years’ time there will be discernible differences and patients can be assured that their experience of hospital will be safer than it is today.

Back to Top

Respect patients and see health improve

Last month Raymond Tallis — physician, philosopher and poet — was one of the guests on BBC Radio 4’s “Desert Island Discs”. He has devoted much of his medical life to the care of the elderly. One of the points he made was how important it is for old people to be treated with respect: he said that many people find it intrusive and offensive to be addressed by their first name by hospital staff before the invitation to do so is made.

So it is timely that the Department of Health has issued a framework for staff at NHS trusts outlining the benefits for patients of applying human rights — one of which is respect — to health care (p388).

Back to Top